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Thursday, July 15, 2010

Disillusionment

When I went into medicine, I had clear goals in mind. Helping people. A stable income to provide for a family. I grew up under the spotlight of my father, who is a neonatologist, and lived in awe of his work. I remember being in restaurants with my dad - people would come up to him reverently and sing his praises (to his obvious embarrassment). Talk about their son or daughter that he had taken care of, and fill him in on how they were doing now. Once, in a small town in college, I was filling out a check at a convenient store. The clerk recognized my last name as the same one as the doctor that saved their premature baby. "Your dad is amazing. It must have been wonderful growing up with a father like that - one who hung the moon."

So although my path was a little wayward, I found myself starting medical school at 23 years old - not too bad after taking three years post college doing B.A. level psychiatric jobs and taking pre-med requisites. I thought I might be a psychiatrist, but quickly changed my mind because I worried about the burnout I might experience taking on the burden of other's emotional and mental issues. Then I decided to be an ophthalmologist, but changed my mind at the last minute - fall of senior year. This is why. I was on a month away rotation in a different state, and worked closely with an ophthalmologist at the general clinic. She was elegant, razor-sharp, and efficient. I watched her manage the clinics with grace and ease - quickly entering and exiting each room, performing eye exams, dictating notes for the chart. She took me out to lunch. Here is what she said.

"Don't do it. Did you see how many patients I plowed through? It's like that every day - you have to see more and more. Some days I squeeze in 60 or 70. It didn't used to be this way. Did you see me get to talk to a single patient?"

I didn't.

"The techs do all the talking. I don't get to know them at all. I'm like a machine, getting briefed by the techs and looking at their eyes. It's all I get to do. Then I tell the techs what to write in the chart, and have to rush to the next room. Job satisfaction is nil."

My best friend in medical school ended up going into ophthalmology - I'm going to take my kids to visit her this weekend. She works in a small town, and seems to have good patient interactions, but her job is not without its challenges. Overall, she seems happy.

I am reminded of another experience my third year when I was considering orthopedic surgery. I had the grades, and the strength to manipulate the hardware. I was surrounded by encouraging attendings, but they and the residents were all male. I asked if anyone knew any female orthopedic surgeons I could talk to. One of the attendings gave me the name of a woman that rotated once a month from a practice in a smaller town. I called her. She was in her early 50's. Here is what she said:

"I made great sacrifices, for my family, in order to do what I did in my career. If I had to choose all over again, I would choose differently."

The one girl I knew who went into ortho, she was a year above me - bailed for radiology as soon as she started a family.

I encountered a lot of frustration on the pediatric wards when I rotated. The pediatric residents, especially those in the SICU, liked to stay up late talking about how hard they worked and how little money they would get in return, when all was said and done. Massive debts, burnout, and destined for salaries that barely scraped the bottom of the physician barrel. Many residents in the primary care fields appear to share this sentiment.

I was watching a film tonight that my friend Ramona Bates shared with me called "The Vanishing Oath." It messed up in the middle (I think it was my player Ramona), but what I saw was this. An ER doc who sacrificed for many years to study - missing important life events of family and friends along the way - and is now overworked and bogged down in bureaucracy. He feels he has no time to spend with his patients from all the charting and hospital hoops he encounters. A few years out of med school, having barely made a dent in all of his debt, he is ready to get out - or at least take a big sabbatical. I need to give it another shot so I can do a proper review, but the little I saw inspired this post.

I work in the field of pathology. I do have a little patient interaction, but most of my work does not involve patients. I love my job - wouldn't trade it for the world. I have become somewhat disillusioned by how much of a money game it is between hospitals and doctors. I spent a day in a special session of legislature last year, watching a battle, and that was an eye-opener. I am also disillusioned by the lack of teamwork involved. Dr. Gawande said it better than I can in a med school graduation speech at Yale called The Velluvial Matrix that I read earlier this week. It's not that we don't try to work as a team, the system is just set up against us. And it really is our job to figure out how to fix that.

Sometimes when I get really angry and jaded I try to remember that little girl that sat in awe of her dad, through all those chance encounters with the parents of the many babies he helped that would not otherwise have lived. Now I'm doing my own part - although somewhat more behind the scenes. I love calling doctors and telling them the results of their procedures so they can move on to treat the patient. This week, I got to help an enigma of a young girl being treated for a brain tumor with fever and neutropenia. The pulmonologist was so happy when I called to tell her there was pneumocystis all over the GMS (fungal) stain. Something to treat. A cardiothoracic surgeon called me three times, hanging on my assessment of a CT-guided lung biopsy. When I finally called him late in the day to tell him that yes, me and my partner agreed we could name that cancer on three cells so he did not need to proceed to mediastinoscopy - he was overjoyed. One less procedure, and one more step toward treatment. Every day I get to supply a big piece of the puzzle that can help the clinicians move on. That is extremely satisfying.

So my question (after blogging way too much) is - what were your goals when you started medicine? And how have you been disillusioned along the way? What keeps you going?

34 comments:

It's funny, I had a similar early experience with a patient of my dad's. But he's a psychiatrist and I think his patient was demented or something, and he kept me on the phone for like thirty minutes talking about how awesome my father is.

He's the reason I'm a doctor, not because I wanted to be like him so much, but because he said to me, "What the hell else are you going to do?"

I never entirely knew what I was doing entering medicine. I just sort of floated into it, and I really wanted was to have a normal lifestyle and normal hours. The more I learned that wasn't possible, the more disillusioned I became. PM&R saved me (for the most part).

I worked in administration at a community clinic for underserved patients prior to med school, and went into family medicine with the thought of returning to that setting as a physician. Once I got into my training, however, I found medicine to be very stressful (I still have a hard time with the notion that every decision I make could have life or death consequences). I realized that adding to that the difficulty of patients with inadequate insurance and limited resources was more than I could sanely take on. Back in my idealistic pre-med days, I thought that the reason underserved areas couldn't get enough doctors was that doctors wanted to make money more than help people, but now I realize it's much more complicated. I used to think I would be the one to do such important work, but now I have to be content with doing what I'm able to do without getting so burned out that I quit medicine completely. This may sound a bit bleak, but it's not- I'm just helping people in a different way than I had once envisioned.

Family Medicine was my choice for 2 reasons: 1) I wanted to be out in the real world making real dollars before I turned 30 and 2) by about week 5 of every 8 week specialty elective I was disinterested and couldn't imagine seeing the 5 "bread & butter" diagnoses over and over for the rest of my life.

I feel disillusioned on several levels: lack of training in procedural skills, lack of business education in preparation for being self-employed, lack of support to work part-time, and lack of accessibility to child care (I practice in Canada).

I manage my disillusionment by: taking risks and trying new areas of medicine, becoming an executive member of my province's Medical Association and promoting ideas that I believe in (like access to child care), participating in continuing medical education events, and reading blogs like this. So, thanks!

I wonder if disillusionment is proportionate to debt? I am amazed by the tiny maternity leaves taken by this community of bloggers! The lack of holidays. Being unable to take a break to sit and assess life once on the medical treadmill. I have no med-school debt (Australia had a very very low cost system for medical school 15yrs ago- and it was undergraduate so 6yrs long. Cost for 6yrs, probably under $20K but I paid upfront for a massive discount on fees).I'm in family medicine, but am employed (not a partner) so don't have to deal with any red tape really(Universal health care). I quite enjoy the job and do feel that I am "helping people". Its very flexible - basically choose your hours/days. I'm currently on maternity leave with an open ended return date. "Whenever you like, no pressure"So yes- medicine has given me what I want. But I realise that maybe the lack of debt has allowed the low stress part time life that I have wanted. My Father is an Obstetrician, and he always told me never to pursue that speciality if I wanted a family. Though I do have a friend who does work 4 days a week with 3 young girls and she feels she has the family/work balance about right.Rebecca

gcs 15 - ha! I realize the questions are kind of big - just wanting to start a topic. I wrote this blog off the cuff after watching half of that movie, and I thought of a million other things I could have said after the night wore on. Book, yes. Tome.

Fizzy - I chose pathology much for the same reason. Normal lifestyle, normal hours. I hope you love your new job as much as I love mine!

Elizabeth - isn't it so much more complicated than we thought? You don't sound bleak at all, it sounds like you are managing to find a balance, which is wonderful.

k-kel - I hear that so much in family medicine - friends getting frustrated because they don't do procedures, just manage patients for the specialists. A lot go to rural areas so they can do more. I am in awe of those who go out and manage to start a business and be a doctor. What a feat. I'm lucky mine was already going.

Anon#1 - hope you find something you love to do in life, whether it is medicine or something else. One of my good friends from college just left family practice for a government/insurance job - I bumped into him at a restaurant last week. He told me he took a big pay cut, but is very happy.

Rebecca - sounds like you stepped into the right job - and maintained your happiness - I think that is the key. I wonder if it is easier to do in Australia than it is in the U.S. Sounds like you all are one up on the med school debt as well. And the holidays - we are currently picking our vacation for next year and I missed out on the weeks of Christmas, New Year's, and Spring Break. Oh well. Maybe next year. Or maybe I should move to Australia:)

I came into medicine wanting to be a researcher and to do academic medicine. I thought I would do internal medicine. It's possible I still might.

Disillusionment #1 -- Where the heck are all the women? It never occurred to me before I started that there would be so few women in research, or that my gender would be perceived as a handicap AT ALL. At least a few times a month now I receive some sort of reminder that it's going to be especially hard for me "since I'm a woman." I guess maybe this is true, but I have to wonder if it's a bit of a self fulfilling prophesy. I didn't expect to encounter so much sexism in 20freaking10!!

Disillusionment #2 -- The medicine people at my institution. Many of them are not easy to work with. Prissy. Passive aggressive. I actually LOVE medicine -- the whole process in fact including the social issues. I just don't like (most of) the people. OF COURSE there are exceptions. But do I really want to spend my life in a discipline where I don't fit in? Maybe the culture is different elsewhere, I don't know. This has left me thinking about other specialties, such as Neurology (LOVE!), Psych, EM, Anesth. I know, broad selection. Fortunately I have a while to sort these things out.

I guess I'll just have to see how things turn out. I won't have debt when I'm done, most likely, thanks to the MSTP program. If I did, I'm sure I'd be feeling the pressure of the golden handcuffs already.

Gizabeth, what a fabulous post. As a non-medico, I still suffer disillusionment. I love my "job" of being a mother, but there are days when I hang my head. I didn't ask to be a mom; God delivered it. But I wouldn't change it for the world. Yes there are days of sheer frustration, sure. But when I get to see my kids in a show, or win a race, or they just come up to me and say "I love you" (even if it IS 3am!!), it lessens the impact of the thankless grind. Thank you for your post. :)

Disillusionment.... got so bad I quit being a doctor. I am now a stay at home mom to 4. Watching my kids play sports and being involved in school is more fulfilling than being pressured every day to see more and more patients. It is too bad medicine has become what it has.

I'm aware of the shitty system, because I've experienced some of it as a parent and read about it a lot, but I'm not disillusioned yet. I know I will be, though, it is a fact of life in medical training, I think.

Fascinating post. There are a few young moms in my academic faculty group. We are emergency physicians, and are lucky to have a very fair and gender-sensitive chair. Nonetheless, working shiftwork for the rest of our lives, never having time to pee or eat during our shifts, never getting thanked, always wondering when that-one-patient-will-have-a-horrible-unpredictable-disease-and-sue (it has already happened to all of us, and ALL of us are thorough).... It gets exhausting.

So what gets me through? It's the knowledge that I *do* have a relatively flexible schedule, and I *do* get to see my kid a lot of the time. It's the excitement of the unknown (you never know who will walk through the door). And, most of all, it's the research that keeps me sane: the sense that (a) I'm contributing, somehow, to the greater good, and (b) I do have an out, if this ever gets to be too much.

That said... my friends who are not in medicine are not necessarily any happier/more satisfied than I am. Nor are my friends in other specialties. I think there's no perfect answer, and that life today is just darn hard. But I keep trying. :)

Jumping in to say that I don't think disillusionment is a necessary end to medical training. I am not disillusioned. Sure, there are aspects of what I do that frustrate me from time to time but, in general, I love my job. I feel that what I do makes a difference everyday. I think I make a good salary for my training. I can't imagine doing anything else, nor another specialty other than internal medicine.

Caveats: I do not have debt. I am a salaried physician who does not have to deal with the "business" aspects of medicine. I work for an underserved patient population --this is inherently rewarding. I am an educator. The way my job is structured has built-in flexibility: this has been key.

My goals going into medicine were very unclear. Being honest with myself, I wanted the biggest challenge I could think of. I deliberately picked the hardest things - med school, then neurosurgery - to see if I could do it. Oddly enough, I fell in love with patient care and neurosurgery along the way, early on. What a miracle, to be able to open the body, fix a problem, close the body, and the patient survives the experience!

It's been very hard. I expected challenges, especially being a woman in this specialty. You work through and past those things. It's the things I didn't expect that have been hardest.

I didn't expect the nasty politics of medicine, the way "colleagues" treat each other. I didn't expect health care "reform" and the insults our government pelts at us daily. Or the difficulty of running a business, fighting insurance companies, fighting hospital administration, fighting partners. Or the paperwork, the ever-longer time-outs, the pressure to go to hospital employment... it goes on and on.

I'm not disillusioned.

I thought I was when I first read this post. I've thought about it all day. I can't imagine doing anything different. It all boils down to this: If you can make a real difference in one person's life, it's all worthwhile.

I get angry, frustrated, tired, sad, outraged, and disgusted on a daily basis. (I've posted here in anger and exhaustion before.) And then I walk in the office to see a patient who's pain free for the first time in 2 years.

I've sacrificed a lot, but I've gained a lot, too. I have a great family who understands my work; I make time for them. I have the confidence of knowing that I've accomplished what I set out to do years ago. I have skills that people need; I have the joy of having saved lives. I have my independence. I have a good, although very busy, life.

Admittedly, I have no debt, but I am the primary breadwinner and that does produce a certain amount of stress. I don't make as much money as my partners, because I choose to spend more time with my patients.

Every job has its down side. My specialty may be better off than a lot of others right now. Things may get a lot worse, and I may have to make difficult decisions that I don't foresee today. But I don't see myself quitting, because I'm very stubborn, and my patients need me. And I love what I do.

If you really want to know what keeps me going, read the guest post that will follow sometime this weekend. (Thanks, KC.)

And thanks, Gizabeth, for making me take a hard look at what really matters.

My goals going into medicine were very unclear. Being honest with myself, I wanted the biggest challenge I could think of. I deliberately picked the hardest things - med school, then neurosurgery - to see if I could do it. Oddly enough, I fell in love with patient care and neurosurgery along the way, early on. What a miracle, to be able to open the body, fix a problem, close the body, and the patient survives the experience!

It's been very hard. I expected challenges, especially being a woman in this specialty. You work through and past those things. It's the things I didn't expect that have been hardest.

I didn't expect the nasty politics of medicine, the way "colleagues" treat each other. I didn't expect health care "reform" and the insults our government pelts at us daily. Or the difficulty of running a business, fighting insurance companies, fighting hospital administration, fighting partners. Or the paperwork, the ever-longer time-outs, the pressure to go to hospital employment... it goes on and on.

I'm not disillusioned.

I thought I was when I first read this post. I've thought about it all day. I can't imagine doing anything different. It all boils down to this: If you can make a real difference in one person's life, it's all worthwhile.

I get angry, frustrated, tired, sad, outraged, and disgusted on a daily basis. (I've posted here in anger and exhaustion before.) And then I walk in the office to see a patient who's pain free for the first time in 2 years.

I've sacrificed a lot, but I've gained a lot, too. I have a great family who understands my work; I make time for them. I have the confidence of knowing that I've accomplished what I set out to do years ago. I have skills that people need; I have the joy of having saved lives. I have my independence. I have a good, although very busy, life.

Admittedly, I have no debt, but I am the primary breadwinner and that does produce a certain amount of stress. I don't make as much money as my partners, because I choose to spend more time with my patients.

Every job has its down side. My specialty may be better off than a lot of others right now. Things may get a lot worse, and I may have to make difficult decisions that I don't foresee today. But I don't see myself quitting, because I'm very stubborn, and my patients need me. And I love what I do.

If you really want to know what keeps me going, read the guest post that will follow sometime this weekend. (Thanks, KC.)

And thanks, Gizabeth, for making me take a hard look at what really matters.

Rock Star M.D. girl - I feel you on the gender differences. Every time I walk into the doctor's lounge I feel like I am an outsider barging into a men's country club poker lounge. They are all sitting around watching FOX news and talking sports. But my group is wonderfully, incredibly diverse and the lounge is also noticeably better in my three years at this hospital.

At the risk of being called out, I would like to say that I observed that academic research, and my years of working as a genetics underling in academic research, taught me that the personalities involved can be very petty and passive aggressive. That is some cutthroat stuff - with entire careers resting on endless work. I went into medicine because I thought getting an M.D. would be easier than a Ph.D.

It's nice that you still have your choices ahead of you. Don't let yourself get locked in too early.

Thanks Ramona! I can tell from your blog that you are an excellent clinician with wonderful patient interactions. Any patient of yours is privileged to have you in their corner.

Jabulani - thanks! Great to see you here. Isn't it so easy to step outside of the box and apply simple lessons to every profession? Thanks for pointing that out. I'll bet you are a great mom - those of us who have healthy doubts are usually the best.

Anon - two of my good friends in med school did just what you did, and both are very happy. One was an all-star who did a fellowship at Duke and quit medicine when she had a son with special needs. The other has four kids, like yourself. I am sad that disillusionment drove you to quit, but happy that you have your kids to fulfill you. I cannot tell you how many days during my residency I almost quit - and was so jealous of SAHMs.

Kyla - I know you are well aware of the system, with all you have been through with your family. As I have commented before on your blog - you will make an amazingly empathic doctor. Keep going.

MLR - looks like you found a better job than that guy on The Vanishing Oath. I always thought shift work would be great for a family life but I'll bet some of those shifts can be really long. Glad you are finding happiness and fulfillment. As Jabulani said above - and you echoed - we are all disillusioned to a certain extent - with life, job, etc.

KC - I don't think disillusionment is a necessary end, either, but I think to ignore that we all encounter it somewhere along the line put us in denial. Sounds like you have a fabulous job - I am starting to see that it makes all of the difference.

gcs15 - thanks for weighing in with your book chapter:). I will never forget your last post here (tears in my coffee cup) and am really looking forward to seeing what keeps you going. I don't think I am disillusioned either, but as we move along in life and medicine we gain knowledge and experience that don't jive with our fresh-faced twenty-something ideals of what it is like to be a doctor. That's not a bad thing, it is just reality.

I trained in a combined family medicine and psychiatry program (5 year program) and just finished June 2009, but I have to say that I love going to work. I have a 23 month old daughter and love being home with her and my palliative psychiatry husband, but could not imagine life without the challenges and joys of my (many) jobs: running a subspecialty maternal mental health clinic at an academic med center, providing primary care two sessions per week on a free mobile health clinic and doing psychiatry consults in the family med clinic for colleagues. It's a hectic week and I'm only 70% clinical time (though I work 80-90% with admin responsibilities) but I love the variety and the intellectual challenges. Every day I think I make a difference in someone's life, and the ongoing challenge of building the subspecialty program (i started it in residency from scratch--how can a large academic center have no specialist in reproductive psychiatry????) keeps me motivated to look at the business side of things in an exciting, rather than hassled, light. I think if I focused on just one setting of care, however, I would get disillusioned pretty quickly--it's too easy to get into a pattern of complaining in one of my departments. Thanks for the post--after reflecting on it all day I remembered that I really love my jobs!

I am not even a doctor yet, and I am wondering if I made the right decision. I think it would be great if I was childless. But, if I was childless, I don't think I would be where I am or who I am. I most certainly wouldn't be as interested / informed on obstetrics, which pretty much feeds my passion for medicine.

I think I will love providing care to pregnant women, and reproductive care. I am just really, really dreading the match process and residency right now, mostly because I am a single mom.

Disillusionment is sometimes a daily event. I stayed in academics because I knew business is not my forte. Then I got overwhelmed by clinical demands such that my research went by the wayside. Then my girls arrived. Now the world of medicine has changed enough that - have to worry about billong enough. Precisely what I did not want. And my girls ask why I can't go on field trips or bake cookies more often. I am tired and it makes the disillusionment worse.

I am the producer of The Vanishing Oath. I am a mother of 3 and left my position as Director of Social Work at a Boston hospital 4 years ago to take on the film project.

Dr. Ramona Bates is a wonderful human being and I thank her for the level of support she has shown for our mission. Gizabeth, you have written a poignant, heartfelt post. Please keep writing.

I am not a doctor. Only one who has gone through the rigorous requirements it takes to become one can possibly know what it is like.

I have spent the past 4 years researching and examining the minds and hearts of physicians. Having visited the inner sanctum of medicine, I have witnessed the unnecessary obstacles and prohibitive nature of medicine today.

I must admit I have not been able to get a particularly disturbing fact out of my mind. Records indicate that physicians have the highest suicide rate and female physicians reportedly take their own lives more often than their male counterparts.

I must address this issue for any of you who may be suffering with symptoms of depression, post-traumatic disorder or you just haven’t been feeling like yourself for a while. I would be happy to talk with you free of charge and, together, we will collaborate in finding you a therapist in your area. My phone number is 781-828-8955.

Remember, there is nothing more important than your well-being. Nothing.

We seek to honor the integrity of countless physicians who have made great sacrifices for the good of all. I ask for your help in our grassroots campaign of moving the mission of The Vanishing Oath toward the tipping point. Please consider purchasing a copy of The Vanishing Oath for yourselves, family members, colleagues, etc. at www.crashcartproductions.com

Sixty percent of physicians are disillusioned with medicine and as they continue to leave the profession, a gaping hole is forming. When I look into the future I am left to wonder; Who will take care of my children?

KP - thanks for posting about your wonderful job - one thing I am learning is that there are good jobs out there and I would hope the disillusioned would try out more than one before quitting medicine.

Mom TFH - thanks good friend! You are going to be a great advocate for women - you need to stick to it. I think your realism and rocky road in life will help you weather the difficulties. Looking forward to following your journey.

Anon - thanks for sharing. I hope you find a balance between motherhood and medicine. My daughter often asks why I can't drive on field trips and threatens to run away to live at my SAHM friend's house down the street, who "does everything perfectly" - not a criticism - I love my friend. I am looking forward to a time in the future where my daughter respects my choice of being a doctor and a mother.

Nancy Pando - wow. Thanks for gracing this blog with your thoughts and offers for support - I have reached out for therapy over the last year and a half and it has made me a much more effective doctor and mother. I too highly encourage seeking outside help to prevent mental health issues that could be devastating. I know of a doctor/mother in my state who committed suicide about 5 years ago, and of a female doctor who trained my sister, an anesthesia P.A., who died of drug overdose.

I really enjoyed the first half of your documentary and am looking forward to seeing more, which I imagine will inspire future posts. I think the type A personality which drives people to become physicians also inhibits them from admitting that sometimes, you need help.

My goals are also helping people and supporting my family... and at least as an internal medicine resident I get to do both. I know there are challenges ahead, but just today someone said.. "I love your bedside manner." That was really way too kind. Their loved one is critically ill in the ICU and they were thinking of me, and believe me I still have a long ways to go when it comes to everything in medicine. The kindness of others blows me away.

I am a pscyhiatrist--when I started med school, it was obvious to everyone but me that I would end up in this field. I enjoyed many specialties but only felt at home doing psych. I found it was like listening to music that others couldn't hear. I was more troubled by having to ignore people's distress than by spending time understanding it--and when I trained, the psychopharm revolution was just getting rolling. To be able to help people in weeks who had previously spent months in the hospital, or been institutionalized, was just incredible. The dissing of therapists by pharmacologists and vice versa was a pain, and I found I could not do patient care full time, but adding teaching and some courses (which as a psychiatrist I have time for)has been great. In the past two decades, the destructive influence of the health insurance system has been the most dis-illusioning thing. I am insulated by lack of debt (and also by not having to run a small business on the side, the way people who have office staff must do)and now by bailing from the insurance system (which I think is a terrible compromise and one I hope won't last). I am now nearly sixty, and I went to med school at 22-- that makes me PGY 33 and still counting!

>>Records indicate that physicians have the highest suicide rate and female physicians reportedly take their own lives more often than their male counterparts.>>

Reference?

See _Veterinary Record_, 3/27/10. Physicians do indeed have a high suicide rate, but the suicide rate for veterinarians is about twice that for physicians. Look at every stressor present for physicians and it's magnified for veterinarians.

For myself, I hope to be leaving practice next year to begin a residency in pathology, which was my original goal (I love Gizabeth's posts!).

TR - you are right, when you are working so hard - just one little compliment can make your week. We get so much negative feedback (people always remember our mistakes!) that it is nice to get something positive.

juliaink - thanks for chiming in. Such a different, wonderful perspective. I am fascinated by you because you represent my original goal in medicine, and I wonder how one spends their life helping others the way that you do and maintains boundaries and sense of self. Congrats PGY33 - I guess that makes me a PGY9!

Anon - I wonder what practice you are leaving for pathology. If you love pattern recognition and puzzling through lab issues - you will love it. I didn't realize how diverse the field was until I entered it - you will become a truly integral part of the cog, albeit a silent one, and physicians from every specialty (except juliainks and fizzy's, maybe) will depend on your wide knowledge base.

>>If you love pattern recognition and puzzling through lab issues - you will love it.>>

Yes, this is what I love, and what I miss in practice.

>>I didn't realize how diverse the field was until I entered it>>

I'd been considering taking the leap for a while, as I loved pathology in school: I attended gross and histopath rounds as a second year; was on a first-name basis with all of the staff pathologists by third year (they saved specimens for me in the cooler and turned me on to the delights to be found in the _Journal of Veterinary Diagnostic Investigation_); and was treated like one of the residents by fourth year.

Veterinary school graduates, however, are encouraged to practice. Non-practicing veterinary medicine was not often presented as a clear career path while I was in school, even though we were told our degree is "flexible". Non-practicing veterinarians were regarded with suspicion. As a result, I graduated, "earned my bones" in private practice, and gradually realized that as good a clinician as I've become, this is NOT how I'd like to spend the next 30 years of my life. It's incredibly difficult, however, to decide definitively to leave private practice (I'm an owner) and return to school for a 3-5 year residency +/- PhD.

Just as I began to contact faculty members for recommendations, I had the good fortune to encounter a veterinary pathologist mentor purely by chance: she's a client! I had no idea of her profession until she said to me, very quietly and seriously: you should be doing something more productive with your degree. Twenty years ago, she was me.

So we shall see.

In some ways, I envy medical school graduates because you're forced to choose a specialty. Veterinarians can remain pluripotent for life; it's possible to go from mixed practice to cattle repro to small animal to shelter medicine (surgery) without pause. Veterinarians are the MacGyvers of the medical world, and I respect my colleagues deeply because of this, but some of us simply aren't cut out for practice. Had I attended medical school, there's no question: I'd be a pathologist (unless the ID folks kidnapped me!)

Sometimes, I look at animal body fluids and peripheral smears from a vet practice in town. It scares the hell out of me, cause I have no idea what I am looking at. I am extremely broad in my diagnostic categorization - feel like if it was a human specimen I would be coming at it from a century-old pathology perspective. I pray it is enough for the vets to make a therapeutic decision, and my partners assure me it is all they want from us.

At 36, I am making some huge life changes (more in family than career - I am very happy in my career) so I can relate to making hard decisions. My take is why not give it a try? If you are unhappy you can always go back. Week after week, although divorce is tough (and I realize very different from your decision, but best analogy I can come up with), I get so many little reinforcements that I am making the right decision. Sometimes you need to approach your life from a whole new angle to realize how wrong the old one actually was. I spent a long time feeling boxed in by past decisions and status quo. Not the way to live, I assure you.

When I joined my group three years ago, I was asked whether I wanted to be the Director of Chemistry or Microbiology. I had to bite my tongue not to scream Microbiology. There's lots of ID in pathology. There will be no sacrifice there.

Thanks for a glimpse into your fascinating world. I could never have done vet - I just don't have a good comfort level around animals and it makes them skittish. I am much better with people. I admire and respect your profession so much - one that would be much more difficult for me than M.D. At least my patients (the few that I have doing fine needle aspirates and apheresis) talk to me!

>>Sometimes, I look at animal body fluids and peripheral smears from a vet practice in town.>>

Now I have a very basic question: are you an anatomic pathologist or a clinical pathologist, or is this a combined board certification for physicians? Veterinarians can either complete a residency in anatomic pathology OR clinical pathology, and thus become board certified as one or the other (though a few stalwarts, of course, complete two residencies and become double-boarded).

>>It scares the hell out of me, cause I have no idea what I am looking at.>>

Yeah, species differences can be remarkable. That's an underlying principle of veterinary medicine: cats are not small dogs, etc. Zoo animal pathology... now, THAT is a challenge.

>>Sometimes you need to approach your life from a whole new angle to realize how wrong the old one actually was. I spent a long time feeling boxed in by past decisions and status quo. Not the way to live, I assure you.>>

No, it's no way to live. The moment I considered letting go of my identity as a clinician, I felt enormous relief.

>>There's lots of ID in pathology. There will be no sacrifice there.>>

Ah, yes. I had the good fortune to spend a month in a level 3 foreign animal disease research facility during my fourth year of veterinary school. Infectious disease is huge for veterinary pathologists.

>>I could never have done vet - I just don't have a good comfort level around animals and it makes them skittish. I am much better with people.>>

I chose a combined AP/CP residency, which was 5 years at the time (now it is 4). Some residents went AP only or CP only - but they usually decided early to stay in academics, subspecialize, and do research. Most general pathologists need to be able to wear both hats - take care of cases and frozens in the OR, do cytology, and help run the lab. I took combined AP/CP boards (you can spread them out over a couple of years if you want and do separately). I never look at animal surgical cases - usually only peripheral smears or body fluids - and it doesn't happen often. I am also boarded in cytology - did a one year fellowship. Cytology is getting really popular these days - paps are disappearing with the molecular tests but interventional radiology can do wonders in diagnosing and they like to have us there so they can make sure they are getting a good sample.

Ha! Your patients do talk. And you understand them. I would have no freaking idea what they were saying and they would become increasingly agitated and it would get ugly from there.

I find people interaction exhausting to a certain extent as well. I would find myself so drained after a day in a busy clinic and wondered, before I had kids, what I would have to offer them when I got home if every day for the rest of my life was like that. Pathology is the perfect solution. Behind the scenes excitement. And you have your library at your fingertips, with time to open a book (and delve into articles) for those tough but stimulating cases.

Not that I am trying to push you in any particular direction . . . just doling out information:)

Not so for veterinarians - from what I've seen, those who are double boarded tend to stay in academia. How interesting.

Other popular double boarding choices for pathologists include toxicology (no formal residency; usually Master's/PhD prior to board certification) or lab animal medicine (residency followed by board certification).

>>I never look at animal surgical cases - usually only peripheral smears or body fluids - and it doesn't happen often.>>

Any pathologist (MD or DVM) can probably give a decent general interpretation sufficient for directing treatment of a mammal, though legally a physician would consult an ACVP diplomate at her peril. One attractive characteristic of every pathologist I've met is insatiable curiosity, so I don't blame you for investigating the "dark side" when offered the opportunity!

For their pathology needs, veterinarians generally choose either a veterinary school (if practical), a state laboratory (if well-equipped) or one of two large corporate laboratories (okay for the straightforward, but have reputations as biopsy factories). Most of my samples are sent FedEx to a veterinary school, though sometimes this is not practical (body parts, etc.).

>>Ha! Your patients do talk. And you understand them.>>

The owners, my clients, talk to me. With my patients, well, it's similar to what a pediatrician does with pre-verbal children. Very hairy children.

>>I would find myself so drained after a day in a busy clinic>>

Exactly. This is exactly what I realized. At the end of the day, I have nothing left over.

>>you have your library at your fingertips, with time to open a book (and delve into articles) for those tough but stimulating cases.>>

Not a luxury I currently enjoy in practice!

>>Not that I am trying to push you in any particular direction . . . just doling out information:)>>

Oh, my misunderstanding cracked me up. I was imaging you as Dr. Doolittle. I was confused about you speaking of animals as clients (we were encouraged to speak of psychiatric patients as clients - more PC - and I was imagining that there was PC in the animal world, too). Oh yeah the owners. Thanks for straightening me out.

Nice discourse. If you do decide to be a pathologist - look me up someday and let me know how it is going. I don't know any veterinary pathologists.

Mothers in Medicine is a group blog by physician-mothers, writing about the unique challenges and joys of tending to two distinct patient populations, both of whom can be quite demanding. We are on call every. single. day.

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